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99nicu Poll: What solutions for parenteral nutrition do you use in your NICU?


Stefan Johansson

What solutions for parenteral nutrition do you generally use in your NICU?  

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Parenteral nutrition is necessary for critically ill infants, and there are several ways to get solutions for parenteral nutrition.

From mixing own solutions in the NICU to using commercially products "ready-to-use".

What is your current practise regarding the TPN solutions.

I will share the Karolinska way (which we currently discuss to revise...) in a separate post later.

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We use this(LINK) installed in a separate computer in NICU (separated from the main hospital IT network) connected via dedicated network to this (LINK) in the IV room in the Pharmacy.

The TPN instructions are entered into the Abacus software in NICU by the NICU doctor along with pharamacist (who comes and stays in the NICU during the TPN entry). The pharmacist is a boon as she often recognizes problems in the TPN order very early (like when calcium precipitation is very likely, etc).

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We use Dextrose (plus calcium) from the first day. Electrolytes start from the third day. We use 6% of aminoacid solution (we don't have the 10%) and 20% lipid.. Which are commercially available.. We don't have any special unit for making TPN solutions..

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Parenteral nutrition is necessary for critically ill infants, and there are several ways to get solutions for parenteral nutrition.

From mixing own solutions in the NICU to using commercially products "ready-to-use".

What is your current practise regarding the TPN solutions.

I will share the Karolinska way (which we currently discuss to revise...) in a separate post later.

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We order TPN solutions from our hospital pharmacy, individualized for each infant. As we increase fat and protein load over three days, we make one new "recipe" per day over the first three days, and then we usually order TPN solution 2-4 times a week for each patient, depending on water balance, volume target per day etc.

We really aim for individualized nutrition but we feel our strategy is expensive and time consuming, and are looking for ways to simplify. I.e. looking for commercially available TPN solutions, or letting the hospital pharmacy pre-produce a set of "bags" that enable an individualized approach that is "good enough".

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We order TPN solutions from our hospital pharmacy, individualized for each infant. As we increase fat and protein load over three days, we make one new "recipe" per day over the first three days, and then we usually order TPN solution 2-4 times a week for each patient, depending on water balance, volume target per day etc.

We really aim for individualized nutrition but we feel our strategy is expensive and time consuming, and are looking for ways to simplify. I.e. looking for commercially available TPN solutions, or letting the hospital pharmacy pre-produce a set of "bags" that enable an individualized approach that is "good enough".

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The following adverse event happened about 15 years ago, but it occurred on my overnight duty shift, so I can't forget it. Our NICU's norm then was an individual MD-concocted (with the help of a "home-grown" computer software-calculated) recipe every day for patients receiving IV al. The fresh recipe for the first 12 hours of the next 24 hour IV al "dose" was hung at 1800hrs. Around 2200hrs the RN observed something about the baby's behavior that concerned her (I forget exactly what.) She called me, and she continued to investigate on her own also. The baby looked more "puny" than was his norm, but otherwise his findings were non-specific. Among other investigations, the baby's RN did a bedside glucose determination. It was zero. We both were flabbergasted; the baby's bedside glucose was repeated, and again it was zero. A simultaneous "store-bought" laboratory glucose determination was also zero. We gave D25W, and followed blood glucoses which gradually improved. The first and second (not yet entered or hung for the baby, due to be hung at 0600 hrs the following AM) 12-hour IV al bags for that 24 hour period were analyzed by the lab. Instead of finding D15W as we expected from the written IV al recipe order sent to the pharmacy, NEITHER bag contained any glucose at all. It turned out that the pharmacist compounding the child's IV al had simply forgotten to draw up the concentrated dextrose aliquant needed in both IV al bags for that upcoming next 24-hour period. Ostensibly, the short-term followup of the baby was good. I wish I knew and could tell you the results of his Bayley and other developmental assessments over the long term.

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Parenteral nutrition is necessary for critically ill infants, and there are several ways to get solutions for parenteral nutrition.

From mixing own solutions in the NICU to using commercially products "ready-to-use".

What is your current practise regarding the TPN solutions.

I will share the Karolinska way (which we currently discuss to revise...) in a separate post later.

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Dear Margaret Bates Walker

Thanks a lot for the post . It was very valid experience shared

In the unit that I previously worked , we used to make a recipe for parenteral nutrition daily , and then send it off to the pharmacy . However , I now realise a potent problem associated with this practise .

We have started trialling standardised prepacked ( low sodium , high sodium etc preparations ) at the moment . Hence , for most clinical situations , there is a prepacked solution that could be used . However , the variety of such packets can make the whole process a bit tedious .. But most of the time it works . If things go astray , we can always manage with add on electrolytes and fluids through a separate line . Although cumbersome , I found this a bit safer option ( especially after I read your post on the incident that happened ) .

Thank you very much

Regards

Gopan

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The center where I was trained -

1. Atleast two of the trainees would calculate the TPN for each neonate separately and cross check

2. One of the trainees would scrub and prepare TPN laminar flow with all aseptic precautions and label each

3. Cross check again before connecting to IV

4. Ofcourse the component varied according to bld glucose, electrolytes & RFT/LFTs, taking care of non-protein calories.

Thanks

Mallikarjuna

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  • 2 weeks later...
  • 1 year later...

In our NICU at the Pedro de Elizalde Pediatric Hospital of Buenos aires, Argentine we use TPN solutions preparred by external pharmacies on an individual prescription. TPN solutions are administred by peripheral o central veins according the osmolarity of the solution. Usually we use Intralipd 20% but when we cope with hepatic cholestasis we use SMOF lipids provided by Fresenius Kabi.

Abel Menalled MD,

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